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General NPI Number Information
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NPI Number | 1700484151
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Entity Type | Individual
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Provider Name | DR. FRED RONALD WAXENBERG
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Gender | Male
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Dates
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Enumeration Date | 10/16/2020
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Last Update Date | 10/22/2020
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Provider Practice Location Address
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Address Line | 3001 HEWLETT AVE
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City | MERRICK
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State | NY
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Zip | 11566-5312
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Country | US
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Telephone | 516-987-2351
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Fax |
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Provider Business Mailing Address
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Address Line | 3001 HEWLETT AVE
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City | MERRICK
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State | NY
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Zip | 11566-5312
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Country | US
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Telephone | 516-987-2351
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC1900X
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Taxonomy Name | Counseling Psychologist
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License Number | 0006472
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License Number State | NY
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